Provider Demographics
NPI:1801426192
Name:DO, TAM
Entity type:Individual
Prefix:
First Name:TAM
Middle Name:
Last Name:DO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18111 BROOKHURST ST STE 5400
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 BRISTOL ST STE B205
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5948
Practice Address - Country:US
Practice Address - Phone:949-274-4323
Practice Address - Fax:949-274-4323
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-25
Last Update Date:2025-04-05
Deactivation Date:2020-08-10
Deactivation Code:
Reactivation Date:2024-06-20
Provider Licenses
StateLicense IDTaxonomies
CA95017595363L00000X, 363LF0000X, 363LP0808X
CA821097163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse